Basic Information
| Provider Information | |||||||||
| NPI: | 1710962048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHENG | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 EAST GRANT STREET | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614553315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098379926 | ||||||||
| FaxNumber: | 3098331417 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 EAST GRANT STREET | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614553315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098379926 | ||||||||
| FaxNumber: | 3098331417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 01/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 05532012 | 01 | IL | BCBS OF IL | OTHER |